MED. RADIOLOGY PYELONEPHRITIS · CHRONIC pyelonephritis is a generic term meaning different things...
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POSTGRAD. MED. J. (1965), 41, 477 THE RADIOLOGY OF CHRONIC PYELONEPHRITIS C. J. HODSON, F.R.C.P., F.F.R. X-ray Diagnostic Dept., University College Hospital, W.C.l. CHRONIC pyelonephritis is a generic term meaning different things to different people. To perhaps the majority it signifies the small, coarsely scarred kidney of what is also known as "atrophic pyelonephritis", which gives rise to hypertension in young people, or, if it is bilateral to renal failure and death. To some it embodies a histological picture which may be found in many conditions and which it is not always possible to associate closely with infection. To the clinician it means recurrent or relapsing urinary infection, and it is notor- iously lacking in clearly defined clinical features in many instances. To the bacteriolo- gist it is a state in which abnormal numbers of bacteria appear, or may be caused to appear, in the urine from time to time. There is in fact no single entity which includes all these requirements, all the time. Nor indeed were it reasonable to expect one in so complicated an organ, any more than the term 'chronic lung infection' might be expected to refer to suppurative pneumonitis rather than cavitating tuberculosis. Radiology's contribution to this subject is that it can define a coarse renal scar by excretion pyelography, and it enables both Wan early diagnosis to be made and the natural history of the disease to be studied. The sign of a scar is a localised loss in thickness of the renal substance. There is usually disappearance of the adjacent pyramid also. (Fig. 1). The definition of this lesion, therefore, depends on the demonstration, during pyelography, of both the renal outlines and the calycine details, which in turn depends on care with radiographic technique and the preparation of the patient's abdomen before examination. We have shown that this is a perfectly possible everyday matter in a busy X-ray department. (Fig. 2). Such scarring is essentially irregular in its distribution, albeit it tends to occur in certain patterns. It is therefore to be distinguished from the uniform change seen equally through- e........ o. ...T...:...:..: ..... N FIG. I.-Pyelonephritic scarring. Female, 19 years. BP 190/120 mm. Hg. No symptoms. Unilateral vesico-ureteric reflux. Specimen shows a normal pyramid and renal substance below which is a scar with absent pyramid and surface depression. (By kind permission of Messrs. J. & A. Churchill Ltd., London). out the kidney in back pressure atrophy, which also leads to gradual disappearance of renal pyramids and narrowing of renal substance. (Fig. 3). It is to be distinguished from infarction in that in the latter condition the renal pyramid survives, although usually diminished in size, and the typical calyceal clubbing does not occur, while the distribution of infarcts also tends to be quite different from pyelonephritic scars, (Smith, 1962). Reflux of urine from the bladder into the ureters, at rest or during micturition, is now an accepted concomitant of this gross form of scarring in a majority of cases, and can be demonstrated by the voiding cystourethrogram. (Fig. 4). The scarred kidney, unless complicated by .... ..... copyright. on June 3, 2020 by guest. Protected by http://pmj.bmj.com/ Postgrad Med J: first published as 10.1136/pgmj.41.478.477 on 1 August 1965. Downloaded from
Transcript of MED. RADIOLOGY PYELONEPHRITIS · CHRONIC pyelonephritis is a generic term meaning different things...
POSTGRAD. MED. J. (1965), 41, 477
THE RADIOLOGY OF CHRONICPYELONEPHRITIS
C. J. HODSON, F.R.C.P., F.F.R.X-ray Diagnostic Dept.,
University College Hospital, W.C.l.
CHRONIC pyelonephritis is a generic termmeaning different things to different people.To perhaps the majority it signifies the small,coarsely scarred kidney of what is also knownas "atrophic pyelonephritis", which gives riseto hypertension in young people, or, if it isbilateral to renal failure and death. To someit embodies a histological picture which maybe found in many conditions and which it isnot always possible to associate closely withinfection. To the clinician it means recurrentor relapsing urinary infection, and it is notor-iously lacking in clearly defined clinicalfeatures in many instances. To the bacteriolo-gist it is a state in which abnormal numbers ofbacteria appear, or may be caused to appear,in the urine from time to time.
There is in fact no single entity whichincludes all these requirements, all the time.Nor indeed were it reasonable to expect onein so complicated an organ, any more thanthe term 'chronic lung infection' might beexpected to refer to suppurative pneumonitisrather than cavitating tuberculosis.
Radiology's contribution to this subject isthat it can define a coarse renal scar byexcretion pyelography, and it enables bothWan early diagnosis to be made and the naturalhistory of the disease to be studied.The sign of a scar is a localised loss in
thickness of the renal substance. There isusually disappearance of the adjacent pyramidalso. (Fig. 1). The definition of this lesion,therefore, depends on the demonstration, duringpyelography, of both the renal outlines and thecalycine details, which in turn depends on carewith radiographic technique and the preparationof the patient's abdomen before examination.We have shown that this is a perfectly possibleeveryday matter in a busy X-ray department.(Fig. 2).Such scarring is essentially irregular in its
distribution, albeit it tends to occur in certainpatterns. It is therefore to be distinguishedfrom the uniform change seen equally through-
e........o. ...T...:...:..:
.....
N
FIG. I.-Pyelonephritic scarring. Female, 19 years.BP 190/120 mm. Hg. No symptoms. Unilateralvesico-ureteric reflux. Specimen shows a normalpyramid and renal substance below which is ascar with absent pyramid and surface depression.(By kind permission of Messrs. J. & A. ChurchillLtd., London).
out the kidney in back pressure atrophy, whichalso leads to gradual disappearance of renalpyramids and narrowing of renal substance.(Fig. 3).
It is to be distinguished from infarction inthat in the latter condition the renal pyramidsurvives, although usually diminished in size,and the typical calyceal clubbing does notoccur, while the distribution of infarcts alsotends to be quite different from pyelonephriticscars, (Smith, 1962).
Reflux of urine from the bladder into theureters, at rest or during micturition, is nowan accepted concomitant of this gross form ofscarring in a majority of cases, and can bedemonstrated by the voiding cystourethrogram.(Fig. 4).The scarred kidney, unless complicated by
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.....
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POSTGRADUATE MEDICAL JOURNAL
FIG. 2.-Pyelonephritic scarring in the upper and lower poles of the right kidney in a girl ot7 years with bilateral vesico-ureteric reflux. 2-year history of recurrent urinary infection.Note marked narrowing -of renal substance compared with the rest of the kidney and theopposite side.
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FIG. 3.-Back-pressure atrophy: IVP showing diffuse atrophy of the renal substance withuniform generalised blunting of the renal pyramids. Non-opaque stone in lowermostcalyx. No reflux.
August, 1965478
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August, 1965 HODSON: The Radiology of Chronic Pyelonephritis 479
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FIG. 4.-Severe bilateral vesico-ureteric reflux in aboy aged 20 months with an apparently normalurethra. Cystogram, before micturition hasstarted, showing reflux at rest. Pyelonephriticscarring was present throughout both kidneys.
some other factor such as previous hypertrophy,is reduced in size and progressive scarring canbe seen by means of serial pyelograms toproduce progressive shrinkage of renal tissue.(Fig. 5). In the growing kidney, moreover, acessation of growth commonly follows, inunilateral cases, on the affected side; whenbilateral, both kidneys tend to be small, onebeing more so than the other.Having commenced the study of chronic
pyelonephritis among adult patents referredlargely from a hypertensive clinic, it soonbecame noticeable that there was a highincidence of such cases among children withurinary infection, and yet further experiencerevealed that coarse pyelonephritic scarringwas the commonest renal lesion in the child-hood population which is referred to hospitalfor investigation.An analysis of our first 100 cases of renal
scarnng which were diagnosed radiologicallyconfirmed this impression, the highest incidenceof scarring being between 10 and 15 years.(Fig. 6). This in turn led to a comprehensiveanalysis of 200 consecutive cases of urinaryinfection in children under the. age of 12 years,which has -recently been published. (Smellie,Hodson, Edwards and Normand, 1964). Thisshowed an incidence of pyelonephritic scarsin 13% of patients investigated, all of thembeing under the age of 6 years.The second impressive finding in these
surveys is that the number of cases of scarring
A.R.: Born 1.4.55
2.6.62 1.1.60 1.1.60 2.6.62
FIG. 5.-Progressive pyelonephritic scarring: tracingsof the pyelograms of a girl at the ages of 4* and7 years. Persistent urinary infection and severebilateral vesico-ureteric reflux was present. (Thedotted lines represent the average kidney lengthsfor these ages.)
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480 POSTGRADUATE MEDICAL JOURNAL August, 1965
32-
28-
24-
20-
16-
12-
8-
4-
0' 10 20 3b 40b 50 60 70yrs.
FIG. 6.-Graph showing the incidence of pyelone-phritic scarring in 100 consecutive cases relatedto age (corrected for age incidence of pyelographyexaminations).
rapidly decreases up to the age of 45 years,with a small rise again between the ages of 50and 65 years. This is particularly true ofbilateral cases, and the only conclusion to be
reached is that these patients die within thefirst three decades of life. In support of thisis the large number of children showing rapid,progressive scarring when urinary infection isuncontrolled, and the very few adults (apartfrom neurological cases) in which scarring isnoticed. Indeed in the three adult cases inwhich we have seen scars develop while underobservation, two followed operations on thelower end of a ureter and were associated withvesico-ureteric reflux, the third happening ina patient with already advanced bilateraldisease.
It seems reasonable, therefore, to look onthis condition of atrophic pyelonephritis as achildhood disease persisting into early adultlife, and indeed most writers in the past, whosestudies have included children, have supportedthis view. Radiology appears to be a mostvaluable weapon with which to both diagnoseand follow up these cases, and the problemas now defined is to evolve a simple andeffective method of detecting urinary infectionin the very young. Clinical methods are notori-ously inadequate in this respect. What isrequired is a simple bacteriological techniqueapplicable to out-patient and home surround-ings.
REFERENCESSMELLIE, J., HODSON, C. J., EDWARDS, D., andNORMAND, C. (1964): Clinical and RadiologicalFeatures of Urinary Infection in Childhood, Brit.med. J., ii, 1222.
SMITH, J. F. (1962): The Diagnosis of the Scars ofChronic Pyelonephritis, J. clin. Path., 15, 522.
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